General questions regarding the episodes:

1. How did you find out your dog might be suffering from CECS/Spike’s Disease?
   

2. Has your dog ever shown signs of unexplainable strange episodes, spells, shaking, or excessive stretching?   YES      NO

3. At what age was the onset of CECS/SD symptoms first observed?
   1-3 years   
   4-6 years  
   6-8 years
   Over 8 years

4. Does your dog behave abnormally before an episode? If so please describe:
   

5. How long do the episode’s last?
   0-1 minute
   1-4 minutes
   5-10 minutes
   10-30 minutes
   Longer

6. How often do these episodes occur?
   

7. Have you noticed any change in the duration and intensity since your dog had his first episode?     YES      NO

8. Have you noticed anything that you might consider a ‘trigger’ to your dog’s episodes? If answer is "YES", please mark the noted cause:
   
   Extreme excitement
   Stress
   Changing weather or extremes in the weather
   Food
   Treats
   Change in environment
   Vaccinations
   Surgery
   Interrupted sleep patterns
   Other

9. If you marked anything in Question #8, please explain:
   

10. Have you noticed any clusters of episodes? (Clusters are a cramping episode, followed by a period of recovery, then having another episode immediately after the recovery.)  YES      NO

Symptoms displayed during the episode:

11. Does the dog appear conscious or responsive to you?  YES      NO

12. Does the dog (please mark each behavior that applies during an episode):
    
    Stand
    Sit
    Fall down
    Lie down
    Drool
    Throw up bile
    Shake or tremble
    Act dizzy
    Lose control of bladder or bowel
    Stretch excessively
    Show signs of stiffness or pain
    Move toward you when called
    Show repetitive motions
    Accept food or a treat
    Refuse food or treat
    Other (Please explain below)
    

13. What does the dog’s mental state appear to be during an episode? (Mark each that applies.)
    
    Fear or Anxiety
    Exhibit signs of wanting to isolate or hide
    Insecure and wanting to be held

14. Does he have visible signs of muscle cramping? If so, what part/parts of the body are affected?
    
    Head & neck
    Shoulders & front legs
    Abdomen and lumbar (back) region
    Rear legs & feet
    Tail (sometimes arches)

15. Does the dog suffer from loud intestinal noises, cramping and/or apparent pain during an episode which affects the intestines?   YES      NO

After an episode:

16. Does your dog behave abnormally for a period of time immediately after the episode?   YES        NO

17. How long after does it typically take your dog until he/she is behaving normally again:
    
    Less than 5 minutes
    5-10 minutes
    10-30 minutes
    Longer

18. Have you ever noticed any of the following immediately following an episode?
    
    Blood in the feces
    Diarrhea
    Mucus in the stool
    Rise in body temperature
    Rapid heart rate

19. Did you have your vet examine your dog because of these episodes?
    YES       NO

20. Have you ever taken your dog to your veterinarian to get medical intervention to stop the episodes?  YES       NO

21. Was the dog’s blood tested and if YES, what was he/she tested for?

CBC/Serum chemistries	Not performed	Normal	Abnormal	Don't know results
Liver function (Bile acids or ammonia)	Not performed	Normal	Abnormal	Don't know results
Bile Acid Stimulation Test	Not performed	Normal	Abnormal	Don't know results
Ultrasound of liver	Not performed	Normal	Abnormal	Don't know results
CT or MRI	Not performed	Normal	Abnormal	Don't know results
EEG	Not performed	Normal	Abnormal	Don't know results

If possible, please send a copy of the original test results sheet. (Contact Kris Blake for address of where to send. If you have a problem filling out this form, please print it and then mail it to Kris after you have filled it out.)

Treatment:

22. Has your vet ever prescribed medication for your dog in relation to his/her episodes?  YES       NO

23. If you answered "YES" to Question #22, list the medication/s and what was the dosage and length of time the dog was on the medication?
    

24. How did the dog respond to this medication?
    

25. Did you stop giving your dog the medication and if YES, what was the reason?
    

26. Have you used any herbal, holistic or supplements on your dog? If so, what kind and what were the results?
    

 Food

27.  What kind of food was your dog on when the episodes first began:
    
    Brand and type (kibble or canned):
    
    
    Other (i.e. home prepared food etc):
    

28. If your dog was given treats/snacks during the time frame of his/her having episodes, what type and brand?
    

29. Have you ever given your dog high protein treats or chews? If so, what kind or type?
    

30. Have you ever tried some of the foods that are mentioned on the CECS/SD site? If YES, what types/brands and what were the results?
    

31. Has your vet ever prescribed a prescription food for your dog? If so, what kind and what were the results?
    
     

The following symptoms may not necessarily be symptoms of CECS/Spike’s Disease, but we would like you to answer the following questions for research purposes:

32. Does your dog suffer from any other kind of medical conditions? If so, please briefly explain:
    

33. Does the dog experience any problems with any of the following?
    
    Ears
    Skin
    Allergies
    Eyes
    Hypothyroidism
    Chronic bowel, urological, or genital difficulties
    Symptoms of Intestinal Bowel Disease

34. Does your dog have a good appetite? If not, please explain:
    

35. Does your dog exhibit any of the following?
    
    Excessive paw licking
    Nose licking
    Licking at the air

36. Has your dog had a reaction to any of the following?
    
    Changes in food or treats
    Inoculations
    De-worming
    Flea control
    Heartworm preventative
    Surgery
    
    If you checked the boxes to any reactions, please explain what occurred: